Jerry is a 48-year old mechanic who is in good health. His parents are healthy,
and he recently got a “clean bill of health” during his annual check-up. Over
the weekend, he helped his brother move across town. Monday morning, he woke
with tightness in his chest. He described it as a “spasm” and thought that he
might have pulled something while he was lifting the sleeper sofa. But someone
in his neighborhood had a heart attack recently, and Jerry’s wife persuaded him
to go to the ED to get it checked out.

A generation ago, Jerry’s family doctor
would probably have told him that he had a muscle strain. He would have left
with some Motrin and felt better. Not so on this particular day. The nurse who
greeted Jerry noted his chief complaint of chest pain and quickly called over a
tech who helped Jerry take off his shirt and attached him to a cardiac monitor.
He was given 4 baby aspirin to chew on. He was brought to a treatment room
where a young doctor came in and asked a series of questions about his chest
pain while a second nurse drew several vials of blood and then sent him off for
x-rays of his chest.

Hours passed. Finally, the doctor in
charge, we’ll him Dr. M., came in and told Jerry that everything looked OK so
far, but that he needed to stay overnight for some more tests.

Jerry didn’t want to stay. He had already
missed his son’s lacrosse game; he didn’t want to miss his daughter’s choir
performance too. Dr. M. told him that he could still be having a heart attack,
and that sounded scary. So Jerry dutifully stayed the night. The next morning,
he found out that he hadn’t had a heart attack. That was good news, but his
ordeal wasn’t over yet. Dr. M. told him that they still could not be sure what
was causing his chest pain or that there weren’t problems with his heart. “You
should see your primary care doctor to follow-up on this,” Dr. M. cautioned.
“He’ll probably want to order some more advanced tests.”

Jerry went home, far from reassured and
more confused than ever. If he didn’t have a heart attack, what could it be?
The discharge instructions just said that he had a diagnosis of “chest pain.”
But isn’t that a symptom, not a diagnosis? His chest was still a little sore—it got
worse after his kids pounced on him when he got home—should he
be worried about this? Is it OK to keep working, what with crawling under all
those cars? Is he going to be OK?

***

Doctors are taught to always think about the
most dangerous things that our patients could have. Headache? Most likely it’s
something benign, but we need to think about subarachnoid hemorrhage. Back
pain? Probably it’s something chronic, but we always ask about continence and
assess for saddle anesthesia and such to make sure it’s not cord compression.
Chest pain? Even in a patient who probably pulled a muscle, we do have to think
about a ripping in the aorta and a heart attack.

It’s the nature of our job to make sure that we assess for
potentially life-threatening conditions. It should also be part of our
responsibility to provide our patients with a diagnosis. Too often, we focus on
the “rule-out” of the really bad stuff: the head bleeds, the strokes, the
appys. When we find that our patients don’t have these (admittedly quite bad)
diagnoses, we are relieved. We tell our patients that they don’t have something
terrible, and for a second, they are relieved too. Then, they wonder what it is
they actually have. To treat a problem, it helps to figure out what the problem
is. It’s part of our duty to provide a diagnosis of not just what patients
don’t have, but what they have, and to tell them what to do about this
less-than-life-threatening condition.

“How can I do this?
We’re really busy; I can’t sit down and go over every single thing on the
differential and what to do about that! Besides, we often can’t offer any
diagnosis at all.”

I would argue that there often is a diagnosis or a “most
likely” diagnosis. We as providers always leave with a provisional diagnosis: the working diagnosis. Why not share this with our patients? It's critical that we involve our patients in the thought process.
Tell your patients what you are thinking. Involve them in your thinking through
the differential diagnosis and the decisions about what tests to do. We can say that
tests so far show it is unlikely you have this terrible life-threatening
condition. Based on your symptoms and physical exam, we think that this working diagnosis is most likely
this diagnosis. This is what you can expect in your symptoms based on the
natural history of your disease. This is what you can do about it to alleviate
the symptoms. This is why you should follow-up with your primary care doctors, and here are
danger signs to look for that should prompt you to seek care sooner. Our patients
are our partners, and it’s part of good care to provide them an answer that
guides their treatment.

In Jerry’s case, think about how differently he would have
felt if Dr. M. had involved him in the decision-making from the beginning. His
symptoms starting after the moving and feeling like “spasms” and his lack of
significant risk factors might not have even prompted a workup for heart attack in the
first place. Instead of being frightened about the risk of a heart attack, Jerry
could have been involved in the decision-making from the get-go and could have
avoided staying for lab work. At the very least, he could have been told after
the two sets AND stress test that his diagnosis was not just “chest pain”, but
musculoskeletal chest pain. He could have been told that the pain could worsen
in the next 24-48 hours, but that it was safe to resume work and exercise. He
could take ibuprofen 600mg every 6 hours with food to help with the pain. He
should see his regular doctor to follow-up in a week if symptoms persist, and to come back
to the E.R. if he has warning signs of something worse (i.e. crushing chest pain,
shortness of breath, etc). If he had been given a diagnosis followed by these
explicit instructions for treatment, Jerry would have gone home sooner,
happier, and far more reassured.

Patients come to their doctors to feel better. Let’s make
sure that even in the busy, often uncertain and unfortunately litigious
environment of modern medicine, we strive to figure out not just how to rule out the bad
stuff, but to provide patients the answer of what is actually causing their
problems. Let’s put the focus back on diagnosis.

Parts of this article have been published in AAEM's Common Sense magazine and on Medscape. I welcome your feedback and comments on the form of patient-centered care that I discuss.

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About Me

I am an emergency physician and public health leader with a passion for patient advocacy. Inspired by my experiences as a caregiver to my mother, I work to educate and empower patients and families so that they receive the best care possible. I received my medical training at Washington University in St. Louis and Brigham and Women's Hospital and Massachusetts General Hospital in Boston, and now serve as the Director of Patient-Centered Care Research, Attending Physician in the Department of Emergency Medicine, and Assistant Professor of Health Policy in the Milken School of Public Health, at George Washington University. My book is When Doctors Don't Listen: How to Avoid Misdiagnoses and Unnecessary Tests; more information at
www.drleanawen.com // @drleanawen